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Ci of Orono � i� � �G`� 2� � Building Permit Application for Maintenance / Replacement / Renovation (No structural expansion. Only windows, doors, siding, re-roof, etc.) MailingAddress: Pertnit number: ��—� `J� �O�O PO Box 66 --- Crystal Bay,MN 55323-0066 Date received: �—I a —1 Street Address: Received by: '►�`'7� yF � 2750 Kelley Parkway Plan reviewfee: � �73• .2� �' Orono,MN 55356 ^� l�kFSH�� i��/� -O-l7 S9 __. Total Fee: Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us This application form must be completed in full and all requir�ed infoRnation must be submitted. Incomplete applications will be returned. (Please print) GENERAL INFORMATION: Job Site Address: n`1� ��'�Up ��iJ-C �\j . Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes No If yes,a special event permit is required with Police Department and City Council approva160 days prior to the event. Shuttle bus service will be required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. CONTRACTOR/APPLJCANT INFORMATfON: Name: l-t�(`ca�� AM�ES C'U1.3'�i R-�C,Z 1 U� State License# t��c�3�c1�,� Expiration Date: ��3� ,�5 Lead Certification Number: �_�- �U��- ��-v�Z2y Expiration Date: (for work on homes that were constructed prar to 1978 Phone: (cell)((.,,`�i� (✓(�J-�I't..t (o�ce) ("j ir3� C-L'��-3 i 1 1 Mailing Address: c �b Ciry: �,,�, ZIP: ��`�'j�j�i �i � 1 r�u(> � ��cU� Contact Person: �.ti.� ��--,,.,h,�,��n��' Applicant is: c!��/ Homeowner �c��ie o�e� Email and/or Fax: '�� c��-��,- \��+�v2s .��w� /��- ( �C�� °-l'Z�1 - 3 t Z`tf PROPERTY OYYNER INFORMATION: Name: I c��c� 1�c��..(� Phone(day): (�t Z��3 i,�K - 7 7 j C> Address: ��i7`� C0.:�C�J ��Il� � C�Y� uX�..�Zc.,��. ZIP: �J'��1 � Email and/or Fax: 7c�j, tix,a� a��o��-�_� u� PROJECT INFORMATION: Overall ro" ct descri tion: ('DDr�� LN'�,�� "`' ��'^�' ��°'�,S ��`�'��'z',�'�, Type of Project: Any earth movement may also require ❑Door(s) �Remodel ❑Fire Damage MCWD review 8�permits: ❑Re�oof,asphalt ❑Repair ❑StoRn Damage Minnehaha Creek Watershed District(MCWD) 18202 Minnetonka Blvd ❑Re�oof,cedar ❑Restoration ❑Water Damage Deephaven,MN 55391 ❑Re-roof,other(specity) ❑Siding ❑Other: (specify) Phone: 952�71-0590 Fax: 952-471-0682 ❑Window(s) www.minnehahacreek.orq . -- ____ —— -- . __—. Estimated Constniction Valuation of Project(excluding land) ; �-10.Uv� � APPLICANT ACKNOWLEDGEMENT: • Agrees to provide all infoRnation required or requested by the Building Department; • Certifies that the infoRnation supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no altemative but to reject it until it is complete; • Some or all of the information that you are asked to provide on this application is Gassified by State law as either private or confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. Confidential data is information which generally cannot be given to either the public or the subjed of the data. Our purpose and intended use of this information is to annually update our records and records of other govemmental agencies required by law. If ou refuse to su pl the inf "on,the a li �on ma not be issued. Applicant's Signature: Date: ��`�� — �� Owner's Signature: Date: �sc u�ted:osrosrzois